ABSITE Review - Biliary Flashcards
What are the borders of the triangle of Calot?
Cystic duct (lateral), CBD (medial), liver (superior)
What is the blood supply of the CBD?
Right hepatic (lateral) and retroduodenal branches of the GDA (medial) supply to the hepatic and CBD (9- and 3-o’clock positions when performing ERCP)
Which layer wall is not present in the gallbladder?
No submucosa
What are the normal sizes of the CBD, GB wall and pancreatic duct?
CBD < 8mm (< 4mm
Pancreatic duct < 4mm
Where is the highest concentration of CCK and secretin?
Duodenum
What is the biliary duct that can leak after a cholecystectomy?
Duct of Luschka
What increases bile excretion?
CCK, secretin, vagal input
What decreases bile excretion?
VIP, somatostatin, sympathetic stimulation
What is the function of the gallbladder?
Forms concentrated bile by active resorption of Na and water
Where occurs the active resorption of conjugated bile acids?
Terminal ileum (50%)
Where occurs the passive resorption of unconjugated bile acids?
Small intestine (45%) and colon (5%)
What give the stool the brown color?
Stercobilin - breakdown product of conjugated bilirubin in gut
What give the urine the yellow color?
Urobilin - breakdown product of conjugated bilirubin in gut; some gets reabsorbed and released in urine
What is the rate-limiting step enzyme in cholesterol synthesis?
HMG CoA reductase
What is the cause of stones in obese vs thin people?
Obese - overactive HMG-CoA reductase
Thin - underactive 7-alpha-hydroxylase
What is the MC type of gallstone in USA? What is the cause?
Nonpigmented stones (75%) Increase cholesterol insolubilization - caused by stasis, Ca nucleation by mucin glycoproteins, and increase water reabsorption from gallbladder
What is the MC type of gallstone worldwide?
Pigmented stones
Caused by solubilization of unconjugated bilirubin with precipitation of Ca bilirubinate and insoluble salts
What is the usual cause of black stones?
Hemolytic disorders or cirrhosis, chronic TPN or pts with ilea resection
What are important factors for the development of black stones?
Increase bilirubin load, decrease hepatic function and bile stasis
What are the stones primarily formed in the CBD? What is the MCC?
Brown stones
MCC - Infection causing deconjugation of bilirubin- E. coli
What is Murphy’s sign?
Patient resists deep inspiration with deep palpation to the RUQ secondary to pain
What are the 3 MC organisms in cholecystitis?
E.coli, Klebsiella, Enterococcus
What are the risk factors for stones?
age > 40, female, obesity, pregnancy, rapid weight loss, vagotomy, TPN (pigmented stones), ileal resection (pigmented stones)
What are the US findings suggestive of acute cholecystitis?
Gallstones, GB thickening (>4mm), pericholecystic fluid
What is a HIDA scan? What is the interpretation of the results?
Technetium taken up by liver and excreted in the biliary tract.
If gallbladder cannot be seen, it is secondary to cystic duct obstruction by stone –> cholecytitis
If < 40% of GB volume excreted after CCK over 1 hour –> biliary dyskenesia
What is emphysematous GB disease? What is the treatment?
Gas in GB wall, usually secondary to C. perfringens, high in diabetics
Tx - Emergent cholecystectomy
What is the MCC of gallstone ileus? What is the treatment?
Fistula between gallbladder and second portion of duodenum that releases stone, causing small bowel obstruction; elderly
Tx - Remove stone with enterotomy proximal to obstruction; perform cholecystectomy and fistula resection if pt can tolerate it
What is the definitive managment of a CBD intraoperative injury based on size?
If <50% the circumference of the CBD, can probably perform primary repair; in all other cases, will likely need hepaticojejunostomy or choledochojejunostomy
What is the MCC of late postoperative biliary strictures?
Ischemia
What is the treatment for early (7days) CBD injuries?
Early - Hepaticojejunostomy
Late - Hepaticojejunostomy in 6-8 weeks
What is hemobilia and what are some of the symptoms?
Fistula between bile duct and hepatic arterial system
Sx - UGI bleed, jaundice, RUQ pain
What is the MC malignancy of the biliary tract? Where the the MC site for metastasis?
GB adenocarcinoma
Noncontiguos liver metastases
What is the risk of GB cancer in a patient with porcelain gallbladder?
10-20%
What are the different stages of gallbladder cancer and respective treatment?
Stage I - limited to mucosa - laparoscopic vs open cholecystectomy
Stage II - into the muscle - Wide resection at liver bed at segments IV and V (2-3cm margins), regional lymphadenectomy
90% present in Stage IV
Laparoscopic approach contraindicated
What are the risk factors for bile duct cancer?
C. sinensis infectio, typhoid, UC, choledochal cysts, sclerosing cholangitis, congenital hepatic fibrosis, chronic bile duct infection
Which is the MC type for bile duct cancer and treatment?
Klastkin tumor - Upper 1/3 –> worst prognosis
Can try lobectomy and stenting of contralateral bile duct if localizedto either lobe
What are the other types for bile duct cancer and treatment?
Middle 1/3 - hepaticojejunostomy
Lower 1/3 - Whipple
What is the MC choledochal cyst?
Type I - fusiform or saccular dilatation of extrahepatic ducts (very dilated)
What is the cause of choledochal cysts?
Abnormal reflux of pancreatic enzymes during development secondary to bad angle of insertion
What is the treatment for a choledochal cyst?
Cyst excision with hepaticojejunostomy and cholecystectomy
What are other types of choledochal cysts?
Type IV - partially intrahepatic
Type V - Caroli’s disease - totally intrahepatic –> will need liver resection
What happens in patients with UC and primary sclerosing cholangitis afte a colon resection?
Primary sclerosing cholangitis does not get better
What is the long term treatment of primary sclerosing cholangitis? Why?
Liver transplant
PSC leads to portal HTN and hepatic failure (scarring and patching with progressive fibrosis of intrahepatic and extrahepatic ducts
What antibodies are present in primary biliary cirrhosis?
Antimitochondrial antibodies
What is the Charcot’s triad?
RUQ pain, fever, jaundice
What is the Reynold’s pentad?
Charcot’s triad + AMS + shock
What is adenomyomatosis?
Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus - Not premalignant.
What is a granunar cell myoblastoma?
Benign neuroectoderm tumor of gallbladder
What size of gallbladder polyp is worrisome for malignancy?
> 1cm
What is Mirizzi syndrome?
Compression of the common hepatic duct by a stone in the infundibulum of the gallbladder or inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct, causing stricture and heaptic duct obstruction
What are indications for asymptomatic cholecystectomy?
Patients undergoing liver transplant or gastric bypass procedure
